Prior Authorization Updates Effective July 1, 2025

G0156

Services of home health/hospice aide in home health or hospice settings, each 15 minutes

L2036

Knee-ankle-foot orthosis (KAFO), full plastic, double upright, with or without free motion knee, with or without free motion ankle, custom fabricated

67904

Repair of blepharoptosis; (tarso) levator resection or advancement, external approach

L0637

Lumbar-sacral orthosis (LSO), sagittal-coronal control, with rigid anterior and posterior frame/panels, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise

L0650

Lumbar-sacral orthosis (LSO), sagittal-coronal control, with rigid anterior and posterior frame/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panel(s), produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, off-the-shelf

31296

Nasal/sinus endoscopy, surgical, with dilation (eg, balloon dilation); frontal sinus ostium

L0648

Lumbar-sacral orthosis (LSO), sagittal control, with rigid anterior and posterior panels, posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, off-the-shelf

L8686

Implantable neurostimulator pulse generator, single array, nonrechargeable, includes extension

L5856

Addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing and stance phase, includes electronic sensor(s), any type

L5700

Replacement, socket, below knee (BK), molded to patient model

L5968

Addition to lower limb prosthesis, multiaxial ankle with swing phase active dorsiflexion feature

L5781

Addition to lower limb prosthesis, vacuum pump, residual limb volume management and moisture evacuation system

K0800

Power operated vehicle, group 1 standard, patient weight capacity up to and including 300 pounds

81257

HBA1/HBA2 (alpha globin 1 and alpha globin 2) (eg, alpha thalassemia, Hb Bart hydrops fetalis syndrome, HbH disease), gene analysis; common deletions or variant (eg, Southeast Asian, Thai, Filipino, Mediterranean, alpha3.7, alpha4.2, alpha20.5, Constant Spring)